The nature of a classic injury doesn’t require much explanation. Life has an all too obvious capacity to break bones, rupture tendons, tear muscle, dislocate joint tissues and rip ligaments. Less serious ‘true injuries’ cause the microscopic equivalents of these major injuries. Microtears to muscle fibre and ligament tissues and the like.
Healthy, strong tissues are highly resilient to damage; if they weren’t, there would be no such thing as contact sports. So true injuries are, without exception, memorable physical events. If you experience a ‘sudden pain’ in your spine picking up a box of tissues, it is worth questioning how healthy your spine is; and whether it really qualifies as a true injury at all.
The most obvious feature of true injuries when they occur is how much they hurt. The purpose of this pain is protective. It is nature’s way of protecting you from the unthinkable horrors of running on a broken ankle bone or ACL tear. When you are injured, the body fires pain signals and releases a cascade of essential inflammatory chemistry. Under normal circumstances, you feel all that as temporary pain and swelling. This pain of injury is absolutely vital for the preservation of life.
Yet, if an injury site hurts for too long or resolves temporarily, then comes back later, it stands to reason that there is something more complex going on. A persistent or recurrent pain after an injury is something that you should pay great care and attention to in the long term. The body is a very sophisticated system. One that seldom (if ever) generates persistent symptoms without a good reason to do so.
The progression in how we manage significant injuries in the past 100 years is a match for the improvements we have made in telecommunications and transport in the same time period.
At the beginning of World War I, as many as 90% of leg fractures were fatal. Most ultimately bled out after being thrown carelessly onto stretchers with no splints or casts. These days, however, almost no one dies of a broken leg, even in war zones. We have truly wondrous high-tech surgical means to preserve life and limbs after major injuries. Yet the longer-term rehabilitation of injury (which is supported by a mountain of scientific literature) still frequently remains an afterthought in today’s frontline healthcare setting.
There is still a dark side to the way we tend to manage injuries in the 21st Century.
Louise was an apparently healthy 32-year-old American lady with lots of curly hair and the look of a world traveller. On first impressions, she seemed pretty normal, if a little stressed.
Once you get talking to Louise, you gradually realise she isn’t living a normal life at all. You also notice after a few minutes that she isn’t able to sit in one position very long, and she constantly moves her body weight in the chair. The other thing you fail to notice right away is that she has some very dark blackish stripes across her face that she partially covers with makeup. These stripes are very distracting once you have noticed them because they are not the colour of any scar or birthmark you have ever seen. They are really, really black, like rubber.
When she was 23, Louise was driving home late one night in the small car her parents had purchased for her 21st birthday. For reasons she can’t explain, at an intersection, she accidentally ran a red light. As she crossed the intersection, her tiny little car was directly hit side-on at 90 mph by a very large commercial vehicle.
The impact was so significant that it crushed her little car like an empty beer can. And in a bizarre, miraculous, incredible, one-in-a-million turn of fate, she seemingly wasn’t injured. She had no broken bones. She had no joint dislocations. She had no damage to her internal organs and no internal bleeding. And there was no brain damage or damage to her spine and central nervous system. She didn’t even have any concussion symptoms.
The only visible injury that Louise presented with at the hospital was two deep indented black marks which extended from her cheekbone across her eye into her forehead. These were caused when the frame of the car window drove itself into her face on impact. When I met her ten years later, she still had two long black stripes so deeply impregnated with rubber that they looked like strange black facial tattoos.
The night she was in the hospital, all her tests were done within less than 2 hours. Then the ED doctors report back to her on the miracle they had discovered. None of her scans or x-rays showed any major trauma whatsoever. The ED doctors confirmed that based on similar crashes, they would have expected her to have sustained multiple life-ending injuries. Yet she didn’t even so much as get a broken wrist for her troubles. All she had was the two black facial lesions.
All in all, after the most extreme car crash imaginable. Louise was congratulated and sent home with a few days worth of codeine and told she wouldn’t even need any follow-up physiotherapy. She was in the hospital for less than 3 hours.
It all seems like a pretty happy story until you hear the rest of it.
Louise went home the night of the crash with a pounding headache. Then when she woke up the next morning, every muscle in her body felt like it had been torn apart. She also felt such an intense pain throughout her spine that she felt like it was literally on fire. The day after the crash, she also had a violently intense migraine that lasted about 3 hours.
Fast forward six months, and Louise was still in just as much pain as she had been the day after the crash. Her whole body ached and throbbed constantly. She also still had debilitating spinal pain and crippling daily headaches. She was unable to work, exercise or socialise. Her family doctor had diligently ordered a second set of scans several weeks after the crash, all of which also came back clear. He had prescribed her some strong painkillers and told her to wait it out in the hope that her body slowly recovered, which it was showing no sign of doing.
A year or so after the injury, she got desperate and took matters into her own hands. She started seeing a chiropractor and a soft tissue therapist. Two years of weekly soft tissue sessions gradually got her muscle pain to a level where she found it manageable. While frequent gentle chiropractic sessions got her migraines down from 7 days a week to 3-4 days a week. Nothing touched the spinal pain, however.
Fast forward ten years, and Louise is sitting in my office on the other side of the world in New Zealand. Shifting around in her chair to take pressure off her back and telling me about the level of chronic pain she lives with.
When she met with me ten years on, Louise literally couldn’t remember a single waking moment without pain since the crash. She had never got rid of the headaches, and the spinal pain had simply never gone away, even for a moment. She estimated that her day-to-day quality of life was about a 4/10 due to the pain. She had long since given up on the career she had planned because she could only work about 20 hours per week, choosing to go on a long-term working holiday instead. She had not played sports or exercised with any intensity since the day of the crash. Her pain had not reduced in any appreciable way in the previous seven years.
It took two more years of intense weekly treatment and spinal rehabilitation to finally get Louise’s pain under control. At this point, she was able to resume a fairly normal life, aside from the ongoing work she requires to prevent the periodic relapses she is still prone to.
All of Louise’s scans and x-rays were clear. Yet the reason for her headaches and spinal pain was clear as day if you know what you are looking for. Her functional spine tests and motion palpation tests (performed by me ten years later) revealed that she had sprained virtually every joint in her spine. These joints remained locked and inflamed a decade later, having never been mobilised. The fascia (connective tissue) around her spine had lost all its elasticity due to widespread scar-like adhesions. And ten years on, the muscles surrounding her spine were so tight it was as if the crash had occurred the previous day.
In other words, Louise’s entire spine had sustained an incredibly severe whiplash injury. And subsequently, they did not even make a partial recovery. Instead, it had transitioned into a chronic unhealed state which included the addition of extensive chronic inflammation and scar tissue. Perhaps none of which is that surprising given the nature and severity of her accident.
Louise’s story contains many grim lessons about how badly our culture can still fail people with pain and injuries.
The obvious healthcare fumble presented by Louise was the complete lack of a diagnosis. It is still common practice to assume that the only injuries worthy of note are those that are identifiable with the limited medical scans and imaging we have. This is a corruption of the ‘disease model’ of healthcare which makes great use of ‘ lab tests’ to identify organic diseases in the body. And also works well for identifying fractures and the like.
The ‘if it isn’t visible on the scan, it didn’t happen’ approach overlooks the elephantine fact that only a micro-fraction of our mechanical pain and injuries can actually be seen using medical scans and tests. The inflammation, joint stiffness and even scar tissue of a severe whiplash cannot be seen on MRI scans, x-rays, CAT Scans or ultrasounds. But that doesn’t mean they don’t exist.
Louis’s case also highlights the fact that we have yet to become a rehab culture in the sense that we are already a surgical and pharmacological culture. The notion that a human body could go through an impact of that magnitude and not need any follow-up physical therapy is outlandish. Admittedly Louise’s case is a particularly extreme example of ‘rehab oversight’. Yet it is a fair reflection of a widespread problem. We still routinely perform major surgeries and discharge major injuries (and pains) without meaningful rehab.
Another grim observation posed by Louis’s terrible suffering is the fact that many injuries simply don’t heal unless they receive substantial encouragement. Many of them seemingly need a great deal of stimulation before the body is able to express its potential for healing.
It is not known why so many of our injuries don’t ‘just heal’ fully.
It’s worth noting that our bodies have a great capacity for strength and fitness, yet without the proper stimulation, they turn to jelly. The same is true of healing. Our bodies don’t need to move much these days, compared with the outdoor life they are evolved for. This ‘sedentary factor’ may at least partially explain why so many injuries fail to heal on their own terms. It would also explain why all injury rehabilitation involves ‘supplementary movement’. To replace the natural movement we are starved of, perhaps?
There is one further thing that is fair to say about Louis’s catastrophic spinal whiplash. It was definitely a true injury – Unlike many of the ‘sudden pains triggered by movement‘ that we call injuries, but are, in fact, something far more complex and insidious.
There is a massive amount more to the topic we call injuries than meets the eye. The life cycle of a true injury is relatively simple. Yet, many of the musculoskeletal injuries we sustain unfold in a manner that is far more complex and concerning, often having far-reaching consequences for our health in the form of slow recovery, relapses, reinjury, chronic pain and chronic disability.
Complex injuries look and feel like true injuries. They are triggered by movement and involve a sudden onset of pain. In reality, however, they are caused by a buildup of repetitive strain that weakens the ‘injured’ tissue long before any symptoms appear.
Miles was 6ft 4 inches tall and routinely squatted 130 kg for reps at the gym. He was one of those men who were born destined to be big. He had heavily supplemented his genetic fate with a lot of weight-lifting over many years. Then one day, he had occasion to pick up a small dog kennel.
Despite the kennel weighing in at a mere 30kg, the lift completely detached Miles’s right bicep tendon at its insertion point on his elbow. When this happens, the visual impact is remarkable. The whole bicep muscle bunches into a tennis ball-like appearance at the top of the arm. And it hurts every bit as much as you would imagine. Surgery was needed to reattach the bicep tendon at the elbow.
Even to the casual observer, Miles’s bicep tear was clearly something more complex than an injury. When a man that strong tears a tendon during such an insignificant lift, it’s pretty clear that something was not right with that tendon. And then there was the fact that Miles had always been one to over-train his well-developed biceps.
Many of the events we call injuries are just like Miles’s bicep. Although admittedly, it often isn’t as obvious that the tissue must have been compromised.
A prospective study of 583 habitual runners (carried out all the way back in 1989) examined factors that predicted the likelihood of running injuries. The researchers identified three factors that accurately predict which runners are most likely to get injured: Running over 64 km per week – previous injury – inexperience. Data like this reflects a universal truth, most ‘injuries’ are not random. An unknown but very high percentage of injuries are caused by factors that lead to repetitive tissue strain and tissue weakening long before the ‘injury event’.
It is common knowledge in rehab circles that there is seldom anything random about ACL sprains, ankle sprains and ‘back injuries’. They all have well-known and predictable precipitating factors. They also don’t spread themselves evenly throughout the active population like random events do, instead tending to happen to certain individuals. This knowledge sits in contrast to the more common cultural belief that injuries are all driven by a combination of luck and the sheer forces at play in the ‘injury moment’.
Many of the sudden pains we name as injuries are not true injuries. They are, in fact, ‘complex injuries’ or even just sudden pains that occur in body parts that already have big problems.
A complex injury is when physical forces cause sudden pain or rupture in tissue that had been previously undermined. Usually by repetitive strain, weakness and/or by a previous ‘true injury’. These forces are often far less extreme than the forces that cause true injuries
The confusing thing about complex injuries is that they often look and feel exactly like true injuries. One minute you don’t have a care in the world; the next, you are in agonising pain, watching your knee swell up. So, to grasp complex injuries, it is necessary to check in with what you most likely already know about the principle of latency—remembering that in life, things aren’t always as they seem.
‘Latency’ is when you are feeling great moments before you die of a massive heart attack. Latency is when you have asthma and IBS, but today you feel great and have no symptoms whatsoever. Latency is the years you spend smoking prior to the cough and emphysema. And latency is also what you are experiencing the moment before you ‘put your back out’ doing some minor DIY task.
The body absolutely does not report all tissue malfunctions at all times; in fact, not even close. If it did, our hunter-gatherer ancestors would have had so many pains and physical symptoms they wouldn’t have been able to hunt, gather and collect water consistently enough to survive.
Your body is deeply invested in the suppression of symptoms associated with everything and anything deemed less biologically important than your immediate survival activities. It has evolved this policy of suppression over millions of years. And if it hadn’t, we wouldn’t be here, let alone be the evolutionary success story we are.
Meanwhile, we have a suspiciously broad spectrum of happenings that we think of as injuries. In fact, we have a strong tendency to identify all sudden pains as injuries.
Let’s split up the type of events we refer to as injuries into five groups so you can reflect on them.
It’s important to be clear these levels are not ‘levels of injury’ – these levels reflect how extreme or un-extreme the circumstances of the supposed ‘injury’ were.
These are the self-explanatory car wrecks and grizzly attacks we rightly refer to as injuries. Most of these involve full-scale rips, tears, joint dislocations or fractures, often within multiple body parts. We can safely call these true injuries. They all involve immense physical forces that would badly injure 100/100 people who experience them.
These are the self-explanatory car wrecks and grizzly attacks we rightly refer to as injuries. Most of these involve full-scale rips, tears, joint dislocations or fractures, often within multiple body parts. We can safely call these true injuries. They all involve immense physical forces that would badly injure 100/100 people who experience them.
These are the likes of significant sports injuries. The ‘big falls’ that tend to lead to a bone breaking, a ligament tear, or some dislocation or other. All of these lead to an extended period of recovery. The overwhelming majority of these events are serious enough to damage the vast majority of bodies.
These are the likes of significant sports injuries. The ‘big falls’ that tend to lead to a bone breaking, a ligament tear, or some dislocation or other. All of these lead to an extended period of recovery. The overwhelming majority of these events are serious enough to damage the vast majority of bodies.
These are the somewhat milder and more random sports injuries. The change of direction while running at a speed that leads to an unexpected but significant sprain or a cruciate ligament tear. A heavy lift at the gym that leads to a ‘back injury’. Some of these lead to extended periods of recovery, and others don’t. These are events that seldom cause problems for healthy people. The % of deadlifts reps that lead to pain is very low.
These are the somewhat milder and more random sports injuries. The change of direction while running at a speed that leads to an unexpected but significant sprain or a cruciate ligament tear. A heavy lift at the gym that leads to a ‘back injury’. Some of these lead to extended periods of recovery, and others don’t. These are events that seldom cause problems for healthy people. The % of deadlifts reps that lead to pain is very low.
These are often ‘somewhat random’ type movements that rarely lead to ‘injury’ but do for some. Picking up a heavy-ish box leads to 2 weeks of back pain. The minor stumbles that lead to sprains. A percentage of these still lead to a lot of pain over an extended period. The incidence of these types of movements causing pain or injury relative to how humans undertake them is infinitesimally small.
These are often ‘somewhat random’ type movements that rarely lead to ‘injury’ but do for some. Picking up a heavy-ish box leads to 2 weeks of back pain. The minor stumbles that lead to sprains. A percentage of these still lead to a lot of pain over an extended period. The incidence of these types of movements causing pain or injury relative to how humans undertake them is infinitesimally small.
The twinges and tweaks that happen during inconceivably minor events but still lead to sudden pain. The sneezes that lead to back or rib pain, minor twisting movements that lead to sudden pain. These can, nonetheless, still leave people incapacitated. Again, what percentage of human sneezes lead to significant episodes of back pain? Is ‘micro-fraction’ a word?
The twinges and tweaks that happen during inconceivably minor events but still lead to sudden pain. The sneezes that lead to back or rib pain, minor twisting movements that lead to sudden pain. These can, nonetheless, still leave people incapacitated. Again, what percentage of human sneezes lead to significant episodes of back pain? Is ‘micro-fraction’ a word?
As you can see, we have had to weave ourselves a very large basket to fit all these supposed ‘injuries’ into. When you see this many differing scenarios getting thrown into one conceptual basket, it pays to be suspicious. Health and life are rarely so simple.
Let’s re-insert a definition of ‘true injury’ that, hopefully, you can agree to.
‘A true injury is a physically traumatic event – where a normal healthy tissue is suddenly overwhelmed – leaving the tissue physically damaged or compromised by the event’.
There’s no question this description applies to many real-life events. The healthiest and strongest bodies have their limits. Virtually all Level 4 & 5 events easily qualify for this injury classification.
Here’s the thing, though, the further down the levels we go, the harder it becomes to make a plausible case that we really showed up to the incident with a truly ‘normal & healthy tissue’.
Here are some practical questions to mull over; answer each of them for yourself based on your own life experience.
If you end up with a ‘knee injury’ just because you marginally increased the amount of gardening or jogging you did for a week… do you genuinely believe that was a strong, healthy knee?
You trip on a curb after two glasses of wine, your ankle is badly sprained, and you still have ankle pain six months later. Do you truly believe that was likely to have been a healthy ankle? Bearing in mind the fact that millions of people have had near identical experiences and recovered quickly/instantly.
Your brother-in-law ends up lying flat on his back for 10 days (unable to even get to the toilet unassisted) after trying to hitch a boat trailer. Do you believe it’s likely he has a healthy, strong back?
Some of us can play season after season of test rugby without a significant shoulder injury. Others can’t get through 6 months of low-key gym exercises without multiple ‘shoulder injuries’. Do you believe the difference is likely to be luck?
Countless millions of people go a whole lifetime without a sprained ankle; others suffer multiple sprains per year for their entire adult lifespan. Knowing this, do you suspect that the people with persistent ‘injuries’ may really be suffering from some form of weakness?
It takes a lot to damage healthy tissue. Healthy tissues can play professional sports, trip, fall, lift and do endless physical work without pain or ‘injury’. Healthy tissues are highly resistant to sudden pains and injuries.
Many sudden pains that look like injuries are ‘tip of the iceberg’ moments – with deep underlying biomechanical issues being their true root cause. Many of these problems have been sitting latently in the body for months or years at a time. It is a well-documented fact, for example, that the natural angle of the knee and the strength of the deep gluteal muscles can predict the likelihood of ACL tears in young athletes. In other words, knees that don’t bear weight efficiently are known to be far more prone to major ligament tears.
Once a tissue is weakened by persistent strain over an extended period of time (e.g. standing on concrete every day with flat feet, running on the tarmac with bad form for long periods, or even just sitting behind a desk for 20 years), it may become undermined. Then almost any small event can trigger pain.
The difference between a trigger and a cause can be a very big difference indeed. Imagine if you believed that tennis truly caused heart attacks, as opposed to being a trigger for heart attacks.
Without understanding the true mechanics of heart disease, you could easily assume tennis was what caused your cardiac arrest. Without understanding heart disease, it seems perfectly logical ‘I played tennis, then I had chest pain; therefore, tennis damaged my heart’.
Understanding that tennis is a trigger for heart attacks, as opposed to a cause of heart attacks, is very important knowledge. Without this knowledge, you wouldn’t respond to the heart attack by giving up smoking, stress and soft drinks – you’d just give up tennis and think your work was done.
For many pain sufferers, the realisation that they suffer from chronic weakness and tissue strain rather than recurrent injuries: is a majorly transformative step towards better health. It opens the door to finding the real causes of pain.
Once you understand the true nature of a physical disorder, it becomes far easier to differentiate causation from coincidence. Just because the heart stopped during tennis, it doesn’t mean the tennis did it.
If you understand that many ‘injuries’ are, in reality, just pain triggers, it frees you up to shift your investigation onto more plausible suspects.
Meanwhile, the damage of complex injury pain is often mistaken for true injuries by patients, doctors and insurance providers alike. If you have had an ‘injury’ or ‘injuries’ in your past, it is entirely possible that the cause was wear and tear to the tissue that finally gave way. Many of us have had this happen and been misdiagnosed with a true injury.
Culturally, we believe very strongly that sudden pains are caused by injury. Patients with new pain often say, ‘I can’t think what I have done?’. This means, ‘I have a new pain, so I must have injured myself, but I can’t remember doing anything significant’. When in reality, if we injure a healthy tissue, it is always a memorable Level 4 or Level 5 event.
Overlooking the vital nuances that separate true injuries from complex injuries being brushed over is a big issue. It’s problematic because the misappropriation largely robs us of the ability to work on prevention and full rehabilitation. Identifying the patterns that led to the injury is the key to preventing further pain and further tissue damage.
True injuries and complex injuries both contribute significantly to the pandemic we live in the midst of.
Pain is a symptom. Symptoms are the feedback that the body generates when it faces problems with its delicate internal balance (homeostasis). Without symptoms like pain, thirst, nausea and fevers, it would be very difficult for us to maintain a healthy body in the same way that it would be hard to drive a car safely with no dashboard display.
John is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all, Let alone the type of running required to play competitive soccer against younger men.
The Old Age Myth